Mixed Vaginitis: The Discharge that Does Not Go Away

Mixed vaginitis should be considered as a differential diagnosis when a person has intermittent, recurring abnormal vaginal symptoms. It is a medical condition that is commonly under-diagnosed. Both patients and attending physicians may encounter frequent flare up of abnormal vaginal symptoms, inability to clear of the symptoms with standard 'quick', 'over-the-counter' medications. The condition can lead to patient's frustration with repeated futile clinic visits and rising medical costs due to inadequate treatment of the condition.

Mixed vaginitis occurs when there is more than one pathogen affecting the lower genital tract, leading to persistent abnormal vaginal infective symptoms. Hitherto, there are over 20 types of lower genital infective pathogens including various bacteria, fungus, mycoplasma, viruses, or protozoa that can result in un-resolving vaginal inflammation.

The aim of this article is to create awareness of this medical condition, encouraging one to consider laboratory testing to evaluate this condition as a differential and receive appropriate treatment without further delay, thereafter reducing the long term morbidities from the disease itself.

What are the common pathogens that cause mixed vaginitis?

Non-STDs	STDs
Candida spp Gardnerella vaginalis Ureaplasma spp	Chlamydia trachomatis Neisseria gonorrhea Trichomonas vaginalis Mycoplasma genitalium Herpes Simplex Virus (HSV) Human Papilloma Virus (HPV)

How does mixed vaginitis occur?

The healthy vagina is covered with dense lactobacillus spp bacteria. Via releasing lactic acid, the lactobacillus spp is able to keep the vagina in a low pH environment, preventing growth of pathogens on the vagina surface lining.

Due to changes in a person’s immune system, hormonal levels, lifestyle habits, intercourse patterns, or infections, this intact vaginal microenvironment can change. There can be depletion of healthy lactobacillus spp and a shift of the vaginal linings in housing more diversified microbiomes. 

In mixed vaginitis, the vaginal microbiome has a mixed floral, allowing the microbiome to escape a person’s own immune response, resistant to antibiotics, making vaginal infection difficult to be eradicated.

Furthermore, certain pathogenic bacteria such as Staphylococcus aureus can ‘piggyback’ yeasts (Candida albicans), resulting in persistent inflammation of the vagina.

Interestingly, pathogenic bacteria such as Streptococcus agalactiae when present in the vagina, can weaken the vaginal mucosal lining immune system, leading to susceptibility of colonization of fungus such as Candida albicans.

To make things worse, with a weakened general vaginal mucosal immune system, lack of healthy lactobacillus, and pH imbalance, the vaginal mucosal becomes a perfect ground for thriving of external STD pathogens such as chlamydia, gonorrhea, herpes, HPV and etc.

What are the signs and symptoms of mixed vaginitis?

It is worth to note that the symptoms that one experiences in mixed vaginitis may have its limitation in determining the cause of the disease inflammation. This is because the symptoms are quite 'generalized'  and non-specific.

Patients tend to present with a constellation of vaginal discomfort symptoms such as

• Abnormal discharge- changes in color, consistencies, volume
• Odorous vagina
• Soreness and burning sensation over the vagina
• Discomfort or painful sexual intercourse
• Spotting or bleeding after intercourse
• Painful urination
• Increase urinary frequency
• In more severe cases, one may even develop low grade fever and pelvic discomfort.

 It can be challenging to attempt to tease out your symptoms on your own. You are advised to consult your healthcare providers for further evaluation of your symptoms. 

How can mixed vaginitis be tested?

While a vaginitis (inflammation of the vagina) can be diagnosed via clinical symptoms of vaginal discomfort and abnormal discharge, diagnosing mixed vaginitis may require a more in-depth medical checkup involving vaginal swab tests. Microscopy smear tests, culture tests, and PCR tests of the vaginal fluid sample can be useful in evaluating the presence of different pathogens in mixed vaginitis, ensuring appropriate targeted treatment to be given. 

You are advised to consult your doctor on your concerning symptoms. If there is suspicion of mixed vaginitis, your doctor may advise for further vaginal tests to evaluate further your condition.

How can I treat mixed vaginitis?

The treatment goal for mixed vaginitis involve resolving vaginal symptoms, eradicating culprit infections/pathogens and rebuilding a robust healthy vaginal flora.

• Combination antimicrobial treatment may be required due to the nature of disease of mixed vaginitis with presence of two or even more pathogens that cause the symptoms.
• Medications can come in the form of topical (cream or ointment), vaginal pessaries or oral tablets.
• Treatment guided solely by symptoms are likely to be ineffective, resulting in incomplete treatment and relapse of symptoms. 
• Treatment targeted on microbial found from vaginal fluid proves to be more superior and effective in the outcome of mixed vaginitis. 
• STDs that concurrently affects the vaginal symptoms should be eradicated as they are treatable and if left untreated, can cause persistent vaginal symptoms. 
• Long term use of vaginal probiotics serves beneficial in rebuilding healthy vaginal lactobacillus spp and minimizing future recurrence.

What will happen if I don't treat mixed vaginitis?

When mixed vaginitis is left untreated, the persistent presence of various pathogenic biofilms in the vagina can carry potential health risk factors:

1. Chronic inflammation and infection of the vagina

One may notice persistent and recurring vaginal discomfort, abnormal discharge symptoms, foul-smelling discharge causing psychological stress, poor quality of life, affecting sexual wellbeing. Complete recovery becomes harder with persistent infection, leading to requiring repeated course of medical treatment.

2. Pelvic inflammatory disease (PID)

Persistent vaginal infection can spread towards adjacent genital or urinary organ leading to a condition known as pelvic inflammatory disease. In pelvic inflammatory disease, one can experience systemic unwell symptoms such as fever, lower pelvic pain, discomfort. If this is left unattended, it can lead to scarring of the reproductive organs and can even cause irreversible damage of the genital structure resulting in infertility.

3. Easier to contracting STD

Weakening and disruption of the normal vaginal floral/ mucosal lining increases the susceptibility of getting infected with STDs. Studies have shown bacterial vaginosis infection when left untreated increases the risk of HIV and other form of STD infections.

4. Higher risk of pregnancy complications and infertility

Vaginitis such as bacterial vaginosis is associated with pregnancy complications such as miscarriage, pre-termed labour, infant with low birth weight and post pregnancy infection.

Untreated mixed vaginitis and pelvic inflammatory disease can increase risk of ectopic pregnancy.

What is the general treatment outcome of mixed vaginitis?

Despite the effectiveness of antimicrobial treatment in managing and treating the causative pathogens, long term recovery can be hindered by recurring infections. While STD causative pathogens upon treatment would not recur (unless there is re-infection), pathogens that are non-STD related can recur due to underlying insufficient healthy vaginal flora. As mentioned above, the key management of mixed vaginitis involve eradicating the pathogens and overtime recovering back to healthy lactobacillus-baseline of the disturbed vaginal flora.

What have I learnt today?

• Mixed vaginitis should be considered as a possible diagnosis in one with persistent recurring abnormal vaginal symptoms.
• Mixed vaginitis is defined as presence of two or more infective pathogens found in the lower reproductive canal, causing un-resolving infection and inflammation.
• Blind treatment solely based on symptoms may be futile in mixed vaginitis.
• Vaginal swab testing has a beneficial role in evaluation the causative pathogens in mixed vaginitis allowing appropriate medications be delivered.
• There is increased in vaginal microbiome diversity in mixed vaginitis, leading to evasiveness of the nature of disease, difficulty in treatment and persistent inflammation.
• Combination of antimicrobial treatment may be required to eradicate the infection(s) in mixed vaginitis and long term probiotics is needed to re-establish a healthy vagina flora.

If you’re experiencing persistent vaginal discharge or discomfort, it’s important not to ignore the signs. Our experienced doctors at Dr. Ben Medical Clinic can provide a proper diagnosis and guide you toward the right treatment. Book a confidential consultation today to get the care you need.

References:

1. Qi W, Li H, Wang C, Li H, Zhang B, Dong M, Fan A, Han C, Xue F. Mixed vaginitis: clinical recommendations regarding presentation, diagnosis and treatment. Advance. 2024 Jan. DOI: 10.22541/au.170667109.93446480/v1
2. Xiao B, A D, Qin H, Mi L, Zhang D. Correlation Analysis of Vaginal Microbiome Changes and Bacterial Vaginosis Plus Vulvovaginal Candidiasis Mixed Vaginitis Prognosis. Front Cell Infect Microbiol. 2022 Mar 8:12:860589.
3. Qi W, Li H, Wang C, Li H, Zhang B, Dong M, Fan A, Han C, Xue F. Recent Advances in Presentation, Diagnosis and Treatment of Mixed Vaginitis. Front Cell Infect Microbiol. 2021 Nov 2;11:759795.
4. Benyas D, Sobel JD. Mixed Vaginitis Due to Bacterial Vaginosis and Candidiasis. Journal of Lower Genital Tract Disease. 2022 Jan; 26(1):68-70.
5. Sobel, J.D., Subramanian, C., Foxman, B. et al. Mixed Vaginitis—More Than Coinfection and With Therapeutic Implications. Curr Infect Dis Rep. 2013; 15(2): 104–108.